Je suis étudiant!

Another intense afternoon at the clinic. Malnutrition and infections are already routine work.

Suddenly arrives a young man of 8 years of age and, well articulated in his words, appears and speaks directly with me, in French: Je suis étudiant!

Son of the arid land of Ambovombe, the little boy tells me about the difficulty in school because he can not see the blackboard. He struggles but has headaches.

He is the only child who attends school for all the children I attended in the entire first week of work. His case was not the priority and seemed absolutely far from our possibilities at the moment. However, #FraternitywithoutBorders was his and his grandmother's only hope

I took a deep breath. I had to do something. And I did...a modified Snellen test was enough to diagnose myopia. Concerned, I tell the translator..."He needs glasses, but we can not offer."

As we have learned in the FWB, we are many united hands working for Love. Dani, my translator and right arm (and left too!) Showed readiness to respond that we had a chance. The next day, we were all going to talk to the priest who had received a mission from the Catholic Church the week before. We introduced the FSF and we got another partner.

A week later, he and his grandmother return to the clinic. Main complaint: a little hand holding a package, a smile that can not be restrained on the lips and a tight hug from anyone who never loses HOPE to see it happen!

Janaina doing the modified Snellen test with the patient during her work 
in Madagascar

Janaine Camargo is a family doctor and works at the NGO Fraternity Without Borders in a rural area in Madagascar

Translated into English by: Bianca Silveira
Posted and Edited by: Ana Júlia Araújo

Healthcare in Kerala : My observation

....having stayed in kerala during my graduation , I found Kerala to be a society full of paradoxes, rather hypocritical to an extent.

Whereas on the one hand you have the best literacy rates and the wow health standards at par with the developed world, on the other you have almost near zero entrepreneurial ventures no industry very limited opportunities of employment outside the government .

One of the highest suicide rates in the country and almost all families have an earning member overseas/outside kerala sending in the dough.

On the one hand female literacy rates are the highest in the country on the other ladies venturing outside their home after sundown were looked down upon,

On the one hand you have the matriarchial society on the other hand ladies are not allowed in the sabrimala temple ( a place of worship in Kerala)

Whereas on the one hand you will not find any coolies on the railway stations but a good chunk are manual labourers in the society.

Whereas you will find them to be admitting to be less than willing to do anything yet their professionalism specially in healthcare is beyond compare, their dedication , zeal and commitment unparalleled.

Health standards were achieved in my opinion because of exemplary societal acceptance of the role of the ladies in the healthcare field specially in the domain of Nursing and teaching.

Whereas men folk ventured to search for employment opportunities beyond Kerala, i.e in the Gulf, America, Europe, or even in other indian states,the women folk continued to manage the native front and ensured education and good healthcare to their children.

As a result even though the governmental expenditure on health was trivial, the out of pocket healthcare was flourishing.

Nothing succeeds like success! once they had carved out a place for their state in the health standard arena they took upon themselves on a war footing as a matter of immense pride to keep it that way and once achieved the government too started to patronise the healthcare in a bigger manner.

If you have travelled through Kerala you would realise that it is an urban village from the northern most district (Kasarkode) to the southern border (Thiruvananathapuram)with almost universally similar facilities all over.

This was probably due to a paradigmal shift by the policy makers regarding resource allocation to local governing bodies called panchayats around 1996, where almost 40 percent of the states available funds were at the disposal of these local bodies for capacity building and development, as per local needs.

Open door policy viz for education in english and hindi ensured education to kids that was utilisable beyond kerala, at the same time not letting go their tradtional cultural traditions i.e mohiniattam, kathakkali, and their gaanamelas,

Notwithstanding what the world said they continued to use coconut oil for cooking relying on their cultural wisdom,only now the entire world is marketing virgin coconut oil for cooking and as cure for some forms of dementia.

Coconut,coffee,cardamom and rubber which were their cash crops peculiar to the weather there continued to attaract world attention because despite all the mechanisation most of these crops continued to be grown traditionally and had their quality and genepool maintained.

Traditionally they eat parboiled rice which is now emerging as a recommendation for diabetics.

With the IT revolution the beauty of kerala became popular and Kerala an important destination for medical tourism specially for the Maldivians and the Lankans. like begets like !! once the dollars started trickling in the industry veterans pumped in even more to ensure world standards.

So,what probably started as a mundane chore of life evolved as the feather in the cap of the nation leave alone Kerala .

Regards

Dr Hemant Saluja

Simplicity

Fábio Schwalm

Home visit in the late afternoon
Hi Dona Ana, how is going the hemodialysis
She responds:
Well, at first it was difficult, I had a bad time ... now I'm fine ... I spend the four hours praying
while I pray
And eating?
Better now I can eat more
And how can we help?
She hold a list in her hands:
What is Damascus?

__

Fábio Schwalm is a Brazilian rural family physician. He works in Brazilian South in a city called Barão. He is learning to write and grew in a rural area working in the smoke farm. 

The day that I dealed with death peacefully

 Andressa Cavalcante Paz e Silva

“When the rain falls down / What brings it back? / Opens the resurrected cloud / From white to black / It's a second birth / For dying skin / In my coffin...” 

(My coffin - Jon Foreman)

I’ve been thinking a lot about this story. Maybe, for some people, it couldn’t be a “Success Story” because in the end the patient dies. But, as a wise once told: In life, it is the journey that matters. So, I’m going to tell you a rural success journey story.

My story begins with a young girl going to a home medical visiting in a little rural area called Curuá, in Baixo Amazonas, north of Brazil. This girl was attending Medicine classes for four years in a College School in Rio Grande do Sul, a state located on the opposite side of Curuá, south of Brazil. However, this story is not about her. This story is about the day she understood the real meaning of Rest in Peace. This girl is me.

It started out with a “Hi, good morning, mrs. Maria. Have you called out for our visit? Let me see how Mr. Manoel is going.” and them the medical interview continued.

-Thank you for being here, doctor, he is not so well. He can’t speak anymore and It is being pretty difficult for him to walk. Also, he is refusing to eat since the day he had this strong diarrhea.

- Oh, and how was this diarrhea, mrs. Maria? You see if he is suffering of pain? Tell me more about it. - The student asked.

- It was last week. It’s been 5 days since the only episode. Oh and those black stools were so so smelly as I’d never had seen!! And in the last two days he is totally constipated. We tried so hard to give him food… We even tried to lay down some pasty food and in his lips and mouth, but the only thing he wants is water and sleep. We are trying so hard to give him the medications another doctor prescribed us, as well as those nutritional supplements. Now he isn’t suffering of pain, but we are worried about inappetence.

Mr. Manoel, an elderly man aged 77, was clearly dehydrated, hypotensive (80x40mmHg) and in the neurological exam we found out Glasgow 10. When we touched his belly during the abdominal exam, his face showed heavy pain. In our hypothesis we conclude that maybe Mr. Manoel was having an upper digestive hemorrhage. 

Unfortunately (or fortunately), the medical conduct wasn’t totally accepted by the family. First, we suggested moving the patient to Santarém, a place with a hospital, in which he could do exams to confirm the bleeding and treat specifically. Nevertheless, the logistic for all transportation stuff and maintenance of the patient and the family in Santarém was really difficult. 

Actually, even if there were no problems at all, Mr. Manoel’s family had already decided he would die at home. “We can’t send him to Santarém… A couple of weeks ago when he was a little better he said that If we ever try to send him to another place instead of here, he would come to haunt us after his death for sure!” - they said. In summary, the elderly man was medicated with some Oral Rehydration Solution and referred to the doctor of the city, as I was only in an observership. This experience was really different and meaningful for me. The empowerment of that family caught my attention and I started to think about empowering my parents and my relatives to understand the finite of life and to embrace palliative care too. Mr. Manoel get better in the consequent day after drinking the oral rehydratation solution, but after two days he died at the crack of dawn. 

So, I’ve been thinking a lot about this story. Maybe, for some people, it couldn’t be a “Success Story” because in the end the patient dies. But, as a wise once told: In life, it is the journey that matters. I guess Mr. Manoel’s journey through death was peaceful and I guess he will not come back to haunt his family. 

Photo by: Keith Dalmon Ferreira

--

Andressa Paz is a Medicine Student living in the South of Brazil. She loves listening to stories and rural ones are her favorite. She had her first contact with rural and remote Medicine in Kat Kalen - Haiti and then in brazilian Amazon area

Its just God's miracle, we are just medium...

         Hello friends.Me Dr.Suhas and my wife Dr. Prerna are specialist by degree but generalist by choice.We both have humble rural background and upbringing.Hence after our post graduation we moved to rural set up for practice as we believe we have many dues towards society and community who helped us to be a good doctor.

        In rural peripheral setup you have a new day new challenge.There are many stories till now in one year. 

But the most interesting one is the 28 year female diagnosed with unexplained infertility for 8 long years. She was investigated & treated at several Super speciality setups at Mumbai, Pune, Nasik, Malegaon, Aurangabad. 

     She even underwent multiple times for diagnostic laparoscopy, hysteroscopy, IUI, IVF & her male partner was also treated for low sperm count in last 8 years but failed every time. Spent lacs of rupees for treatment but every time result was unsuccessful. Husband being rickshaw driver, due to mental frustration gave up hope on for not being able to  become a father. 

               Interesting fact is that the couple was none other than our hospital staff worker's son & daughter in law. 

After we started practice in rural setup, the staff told the story about her son & daughter in law. The couple meanwhile consulted us. Selective investigations were done as all the previous investigations were normal. We studied the case very thoroughly and with help of expert opinion of Dr. Prerna the patient conceived within a month. Her UPT came positive for the first time. 

           The happiness which we saw on her face was priceless. After proper care of thorough 9 months pregnancy she delivered a male child on 23/4/17. Staff worker's son literally cried with happiness. He told us that we are everything for him. And we told him its just God's miracle, we are just medium...

Author

Dr. is Dr.Suhas Pawar is (MS Gen.Surgeon) and his wife Dr.Prerna Pawar MBBS,DGO.They run a rural hospital named Saibaba Hospital, Satana,Nashik. Both belogs to humble rural background and are passionate to provide all super speciality services to rural people in there own community.This shall reduce there trouble to cope up with city urban life.

Grief and resilience on a remote Pacific Island

Dr Nini Wynn

I worked as the sole doctor for five years on one of the outer islands of the Southern Cook Islands, a Pacific Island Nation. The hospital with eight-beds had basic facilities and diagnostics only.  We could not provide advanced Cardiac Life Support because there was no Defibrillator. During my stay on the island, I met a family of five: father, mother and three children – two daughters and one son, who faced three deaths in 4 consecutive years.

The 8 year old boy became ill and when it became apparent that he was not improving he was transferred to Rarotonga, the main island, an hour’s flight away. He was found to have an abdominal lump and was referred on for further investigations and management to Auckland, New Zealand, which involved a 4 hour flight and crossing a national border. 

He was diagnosed there with Nephroblastoma (Wilm’s Tumor). Prognosis was very poor and he died at the Auckland Hospital, far from home. The whole family was devastated and shattered. His body was brought back from New Zealand to the Cook Islands to be buried. Blessings were received after this boy passed away and his mother gave birth to another son. They were all so happy to have a new member in the family. However, a year later, one of their daughters was killed in a motor vehicle accident; she fell off the moving car on the way back from school, sustained a severe head injury and was killed instantly. She was brought into the hospital with no sign of life. The parents were informed and they arrived at the hospital hoping against hope. Her mother held her tightly in her arms and said that she loved her so much - she did not even get a chance to say a few words before her daughter’s last breath. Her father was quite a strong man and we did not see him crying, but we all knew that he must have been crying in his heart.  

Bad luck came in a row to that family –the following year the father became sick. He was 54 years old at that time he presented with epigastric pain and weight loss. He had had the pain for quite a while but did not seek medical attention. Clinically, no positive findings were found and he was referred to Rarotonga for further investigation. There is plain X-ray and ultrasound at Rarotonga hospital but no complex imaging i.e no CT scan or MRI. A gastroscopy was done which showed gastric outlet obstruction and a diagnostic biopsy came back as ‘normal gastric mucosa’. However, his condition did not improve and serious discussions followed with the patient, family and the health team. The possibility was that the biopsy taken might have been insufficient and missed a pathology. There were some issues and controversies during the process of his referral, which caused delays in sending him to tertiary care. When he was finally transferred to Auckland, New Zealand he was diagnosed with inoperable carcinoma of stomach and he died six months later in NZ. He was not well enough to travel home. 

I was amazed at the wife and the mother who had faced three deaths in a row - she was so strong and she dealt with her grief with a real will, whilst taking care of the rest of the family- herself, her eldest daughter and the last born son. She had faced expected and unexpected death. She travelled twice to Auckland and spent precious time with her late son and late husband during the last days of their lives. She respected her husband’s wishes to get treatment with traditional medicine for his cancer, because he believed that it could heal him. He was in a denial stage. As the breadwinner of the family, he had a strong will that he must live on. His priority was his family. He did not want to leave his wife and two children. Even though his wife knew the reality-that her husband was living in his last days, she never argued or went against his wishes. The small community of Cook Islanders based in Auckland, gave her and the family help and support in different ways; psychological, spiritual and financial, during her difficult times. His family accompanied his body back to his home island where he was buried close to his ancestors and his daughter.

When I look back at her story, some questions arose in my mind; would there have been any difference in survival and prognosis of this man and his son if they had lived in a big city with specialist care and advanced modern medical technology? Would the man have survived if the referral had been done more urgently? Is this an example of the health inequality/disparity for people living in rural remote areas? If it is so, could there have been a huge difference to this woman’s life?

What shines through is the resilience shown by the family – the very strong sense of belonging to a place – their island - wanting to be there whether in life or death. This love of their home and their people is perhaps the most important.

About the author

My name is Nini. I live in the Cook Islands, a small Island Nation in the Pacific. My work is in the Outpatient and Emergency Department at Rarotonga Hospital. Rarotonga is the main island of the Cook Islands. Prior to that, I worked in a small hospital on one of the Outer Islands which provides primary health care for the local community.

Currently I am working in a rural hospital in NZ to complete the two six-months placement as a part of the newly established Cook Islands General Practice Training Programme. This programme started in 2014 and was developed by the Cook Islands Ministry of Health in partnership with the University of Otago and the RNZCGP. Before this doctors in the Cook Islands had no Family Practice training pathway."

My story is based on a social and cultural concept on death and dying in rural and remote community – from the time I was working on the Outer Island.

A love story

Una Historia de amor 

Rossana Betancur Escobar

Translated into English by Mayara Floss

Imagene: La pareja.

Con Felipe nos conocimos en el barrio. En un cumpleaños de su hermana.El es 3 años mayor que yo.Nos gustamos apenas nos miramos…empezamos a pololear  a escondidas.

Yo tenia 16 años y el 19 .Pasaron dos años y quedé embarazada….yo me di cuenta que queria ser mamá, pero que era como una ilusión de niña-mujer,de sentir que algo nos unía…Poco a poco  mi guatita creció y mi mamá empezó a preguntarme cosas, sobre mi regla, que por que estaba tan palida…yo traté al máximo de que no supiera, hasta que me puso entre la espada y la pared…no me quedó mas que contarle.Asi que empecé mis controles,a llevar a Felipe a la casa…el mas duro en aceptar  fue mi papá…yo era su regalona..dijo algo asi como que la vida iba a ser mas dura …yo no le hice caso y seguí adelante con la ilusión de tener a mi hijita…ahora ya sabíamos que era niñita…yo me la imaginaba jugando,saliendo al parque , haciéndolo que ella la hiciera feliz,en fin.

Llegó el momento del parto y nos fuimos al hospital…debería haber sido  un momento de alegría..pero no no fue asi…un trabajo de parto largo..una bandita en la guata que mostraba los latidos cada vez  mas lentos de su corazón..la matrona corriendo a avisar el doctor…pasaron las horas mas largas de mi vida…cesárea de urgencia…Felipe y yo nos mirábamos,cual de los dos más asustados….se acercó el doctor de los recién nacidos y nos dice que nuestra hijita viene con un problema…que su cerebro no recibió el suficiente oxigeno…que está como dormida…que necesita una maquina para que no se le olvide respirar…no sabria describir que sentí…mezcla de miedo, rabia,dolor ….pero pensaba…tranquila está viva….

Pasaron los días, y quedó así…como una plantita, conectada a maquinas…que gracias a ella podía seguir viviendo…pasaron muchos meses…tenia una sonda para alimentarse, un tubito en la traquea para respirar,un ventilador , lmonitorizada las 24 horas.Todo estos nombres raros  los aprendí con el tiempo, gracias a la enfermera que la cuidaba , que antes de cualquier procedimiento me contaba lo que le iban a hacer.

Mis padres dejaron de estar ariscos conmigo…hablamos mucho…lloré…me abrazaron…con mi madre nos turnábamos para cuidarla…

Habían pasado varios meses….Felipe no tenia un trabajo estable…empezaron las discusiones..yo estaba tiempo completo para mi hija…no quería pensar en ninguna otra cosa…cuando el decidió alejarse…estuve de acuerdo…eso generó rechazo hacia el de mis padres..pero yo entendí su situación…demasiado jóvenes para comprender lo que estaba pasando.

Mi hija no habla…no se ríe…pero yo se lo que le pasa…ya creo que es mejor irnos a casa.

Nos envían gente del hospital para seguir ayudándonos…algunas cosas las manejo yo mejor que ellos…pero están dispuestos a ayudarme y aprender , cuando tienen dudas me lo dicen , se comunican con su pediatra o los médicos de la unidad…yo lo agradezco….me empiezo a reconciliar con el hospital…no es que yo crea que hay algo malo ahí…solo que cruzar su umbral,vienen todos los recuerdos a mi mente, me falta el aire, empiezo a sudar…

Ya a un año de nacida..me dicen algo sorprendente….ya no hay mas insumos…empieza a fallar el viejo ventilador mecanico….viejo porque no tiene repuestos..pero mi hija sigue viva!!!...sigo peleando con quien sea y donde sea…voy donde el señor donde mandan a mantención las maquinas…invento repuestos…reciclo…vuelve a funcionar….voy a la muni…me dan ayuda económica…estoy agresiva  con medio mundo,incluso en la casa…..me siento angustiada….mi hija está mas inquieta,las maquinas pitean …comprendo que no puedo seguir asi…me visita la kinesologa del hospital….habla con la doctora y ella le pide que me visite la psicóloga….tengo rabia…he luchado tanto y siento que todos me miran diciendo… para que?....como que para qué!!!.....es mi hija …ella me necesita y seguiré luchando por ella…se que sus días son pocos ,pero mientras ella respire, manifieste su dolor, cambien los parámetros de su maquina…..aqui voy a estar….

Ha pasado el tiempo…estoy asumiendo un poco mas mi vida…volví a estudiar…descanso algunas horas….cuando me visitan me traen los insumos, eso es un viaje menos  y un día mas con mi hija...cuando tengo alguna duda los llamo y me siento apoyada…hay una paramédico que se sentó un dia conmigo a conversar y me hizo tan bien.

Hace unas semanas vino Felipe, hablamos , nos perdonamos…le hablamos a la hija…que la amábamos mucho y que aceptábamos su destino….estuvo muchas semanas muy bien..si hasta a un cumpleaños la llevamos…. Con ventilador y todo!.

…Nuestra hija falleció hace unos días…ella fue el regalo mas hermoso que me dio la vida.... pudimos darle la mejor vida que su condición permitió, en su casa, con su gente…superando una  sobrevida , que nadie imaginó!

Estoy embarazada…me fui a vivir con Felipe…tenemos dificultades..como cualquier pareja…pero estamos viviendo nuestro amor con nuevas energias .Sabemos que nuestra segunda hija será única y que no viene a reempalzar a nadie y que nuestra primera hija vino a enseñarnos muchísimas cosas que esperamos poder practicar…

-----------------------------------------------------------------------------------------------

A love story 

Rossana Betancur Escobar

Image: The couple.

I met Felipe in the neighbourhood on his sister's birthday. He was 3 years older than me. We just started to look at each other. We started sneaking around.

I was 16 years old and he was 19. Two years passed and I became pregnant. I realized that I wanted to be a mom, but it was like an illusion of girl-woman, to feel that we have something in common. Little by little my belly grew and my mom started to ask questions; about my periods, why I was so pale; I tried to show that I did not know nothing until she put me between the “sword and the wall”. I had nothing more to tell her. So I started my rituals; brought Felipe home. The hardest to accept this was my dad. I was my father's favourite. He said something like life was going to be harder. But I did not pay attention and I went ahead with the illusion of having my little girl. At that point we already knew that it would be a little girl. I imagined her playing, going to the park and making her happy, in any way.

It was time for the delivery and we went to the hospital. It should have been a moment of joy, but it was not like that; a long labor, something around my belly showed a slower heartbeat and the midwife ran to warn the doctor. The longest hours of my life passed. I needed an emergency cesarean. Felipe and I were looking at each other. I did not know which of us was more frightened. The paediatrician approached and told us that our little girl came with a problem, that her brain did not receive enough oxygen, that she is asleep and needs machines to not forget to breath. I do not know how to describe what I felt, a mixture of fear, anger and pain but I thought to relax as she was alive.

The days passed and she was like this- a little plant connected to machines. Thanks to it  she could continue to live. Many months passed; she had a tube to feed, a tube in the windpipe, a ventilator and monitored 24 hours. All these strange names I learnt over time, thanks to the nurse who cared for her, who before any procedure told me what they were going to do.

My parents stopped being angry with me and we talked a lot. I cried and they hugged me. With my mother we took turns taking care of her. 

It had been several months now. Felipe did not have a stable job and the discussions began. I was full time for my daughter and I did not want to think about anything else. When he decided to leave I agreed but that generated a rejection from my parents. But I understood his situation, we were too young to understand what was going on.

My daughter did not make any sound, she did not laugh but I knew what happened to her and though it was better to go home.They sent people from the hospital to continue helping us; some things I managed better than them. My parents were willing to help me learn, when they had doubts they told me, they communicated with her paediatrician or the doctors of the unit. I appreciated it and I began to reconcile with the hospital, not that I believed there was something wrong there, it just crossed the threshold; all the memories came to my mind, I felt I did not have air, I started to sweat ...





Already a year after her birth and they said something surprising; there were no more supplies, the old mechanical ventilator started to fail because it had no spare parts but my daughter was still alive!!! I continued to fight. I went to the lord, where they sent maintenance to the machines, I invented spare parts, I recycled and it worked again. I went to the major, they gave me financial help. I was aggressive with half the world, even in the house I felt distressed. My daughter was more restless and the machines made loads of sounds. I understood that I could not keep going like that. I visited the physiotherapist of the hospital and I talked to the doctor and she asked me to visit the psychologist. I was angry. I had fought so much and I felt that everyone was looking at me saying fighting for what? .... what!!! ..... She was my daughter, she needed me and I would continue to fight for her. I knew that her days were few, but while she breathed, manifested her pain and changed the parameters of her machine, here I would be ....

Time had passed. I assumed a little more of my life. I went back to study; I rested some hours. When they visited me they brought me the supplies, it was one trip less to get the supplies and one more day with my daughter. When I had some doubts I called and I felt supported. There was a paramedic who sat for a day with me to talk and it made me feel so well.

A few weeks later Felipe came. We talked and forgave each other. We talked to our daughter; we said that we loved her a lot and that we accepted her destiny. We had a good many weeks , she even had her birthday, with her ventilator and everything !

Our daughter passed away a few days ago. She was the most beautiful gift that life gave to me. We were able to give her the best life that her condition allowed, in her house, with her people, surpassing a survival, that no one imagined!

I'm pregnant now. I went to live with Felipe, we had difficulties like any couple but we are living our love with new energies. We know that our second daughter will be unique but she would not replace our first child, our first daughter came to teach us many things that we hope to practice ...

-------------------------------

Rossana Betancur Escobar-resident doctor in Family Medicine at U. de la frontera in Chile. 

I started to write this material as a compilation of life histories of my patients throughout my 9 years of work. It involves mainly rural health with cultural relevance, as Mapuche population predominates in my area, which I respect and greatly admire.

In 2009, I started working in a Health Unit as a family doctor, at Hernan Henriquez Hospital in Temuco, Chile, the unit was responsible for caring for patients affected by acute pathologies to terminal cancer, in their homes.

People come from all over the region and from the city and I continue to attend a large percentage of rural population. I try to get the attention of my colleagues in other specialties, in a hospital of high complexity, to raise awareness about patients being cared at home with the support of their families. So was born this idea to tell patients life stories and how they have experienced sickness.

Today I am working in a rural health center, located in the interior of Mapuche communities and I hope to write more stories.

Project Kamal early screening of hypothyroidism & treatment – A determined journey for wellbeing of community

 Dr Smruti Mandar Haval

Project Kamal hum mm. Sounds cool but what does this means? Are you doing any research or building chain of hospitals? Many people asked me this question with lots of curiosity. Well project Kamal is a gift I have dedicated to my grandmother Mrs. Kamal Gopal Palekar aka Nani. She is the dearest person for me on mother earth.

She is a hypothyroid patient from past 30 + years and underwent two major operations in past. She is a true fighter and a jolly lady. With many good and bad qualities she passed on her hypothyroidism to me. With God’s wish at young age of 28 years I got diagnosed. I was expecting this but not at such an early age. I know the pain of taking daily tablets, regular blood checkup, weight fluctuations, mood swing etc but I was determined to fight back and win this battle.
 

I always felt that females especially are not comfortable in discussing this disease in public. There is lot of unawareness about this, no one voice much about this one as we are more busy in educating people about diabetes, hypertension etc.
 

I did my CCMTD course from Chellaram Diabetes Institute in association with PHFI and learnt a lot more about hypothyroidism than what I already know. During my practice of 2 years in area of Sankeshwar I managed to diagnose many hypothyroidism patients. They all were classic cases missed by many physicians.
 

It used to be a lengthy session to counsel the lady about the disease, its progression, compliance to the drugs, regular treatment, follow up etc. Few used to come back few never turned up. There was a strong need to educate the community about this disease and remove the stigma of being a hypothyroid patient. Need of an awareness campaign was there. So one fine day I was thinking about this cause and it clicked me - a name for my dream Project Kamal. Yes it was the most apt name I can think of. It was working as dedication to my Nani. It was catchy and having lot of meaning wrapped in it.
 

Kamal means lotus. Lotus is a flower with lots of importance in various ancient mythologies and cultures. In Hindu/Buddhist/Egyptian mythology lotus is a symbol of love, fertility, beauty, spirituality, prosperity, wealth and peace … in short symbol of life. This symbol was reflecting the kind of work we wanted to do.
 

So we locked the name project Kamal- Early screening of hypothyroidism and its treatment. Now was the time to take next step promotion and awareness campaign. I happen to read about world thyroid awareness week celebration in month of May every year.as I was near to this month I planned an awareness lecture for common people in my area. This year time frame was 23 may -29 may 2016 so we choose 26 May for our celebration and that’s how our journey started. On 26 May we conducted a lecture in a temple and addressed common people. Told them about thyroid gland, how it is important for body to function normal, what are common diseases of it, what is basic relevant treatment etc.
 

For lecture nearly 60 town people came and were amazed to listen to us as it was a new topic for them to learn. Crowd has few ladies who were already suffering from disease. At the end of session we cleared their doubts or myths too. The stress was on hypothyroidism and its treatment compliance. We gave them nice insight that they are supposed to consume thyroxine tablet till they go the heaven. It worked so well that new patients know their status as whether they are hypothyroid or hypothyroid, what best treatment for them is and how they are supposed to take care of themselves. It was a really satisfying day in my life. Followed by lecture we arranged screening camp of thyroid disorders for which 10 patients enrolled and utilize our services.             
 

We have also started Project Kamal Thyroxine Bank where member patient get thyroxine drug at a reasonable cost or discount rate. This whole activity is to make treatment patient friendly, cost effective and improve compliance of patient especially my rural community. In future we are aiming to arrange more awareness camps, screening camps, improvement in case detection rate etc.
 

 So far we have successfully helped 50 + ladies with hypothyroidism. Number is small but this is just beginning. I hope almighty will give us courage and strength for successful implementation of this activity. Thank you.

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Dr Smruti Mandar Haval  (Dr. Smruti Subhash Nikumbh);  M.B.B.S.D.N.B. (Family Med),M.N.A.M.S.,P.G.D. Diabetology  & Geriatric Med; Certified International Diabetic Educator by Project Hope & International Diabetes Federation (IDF) USA; Consulting Physician in Family medicine, Diabetology, Preventive Cardiology, Thyroid disorders  & Geriatric Medicine; C.E.O. Sukarmayogi Publishers, Sankeshwar Dist: Belgaum, Karnataka; Assistant Professor, Department Family Medicine, USM-KLE IMP,Belgaum

Blog: drsmrutihaval@blogspot.com
        drsmrutimhaval.blogspot.com

Area of practice: Sankeshwar, Dist – Belgaum,Karnataka. Epidemiology of your area in brief: It’s an semi rural area covering more than 50 km radius including many villages. Its USP is it’s an border area connecting borders of Maharashtra and Karnataka which makes it an multiethnic area. Common chronic health diseases are diabetes, hypertension, asthma, hypothyroidism etc.

Mornai - An Experience

Adrija Rahman

It was the year 1993. I have just finished my house-staff-ship in a tertiary hospital in Kolkata and was desperately looking for a job. I was newly married and my husband Shantanu was my batch mate; so, we were in the same boat. Fortunately, we got a job in Mornai, a remote tea estate in Assam in Kokrajhar district. Without much thought, both of us landed up there.

It was a 20-bedded hospital with an out-patient department (OPD), from where we were catering a population of 10,000 people. Apart from us, we only had another homeopathic doctor in our team. 

Locals were mostly Santhali and Mundari and the garden was owned by the Lutheran Evangelical Church.In the beginning, they were quite skeptical about us (by nature, they had the tendency to resist anything new). Moreover, we were facing extreme difficulty to understand their language.With our limited knowledge and unlimited enthusiasm,we started our job. Gradually those tea garden workers started accepting us and after some initial hiccups we also settled down in that isolated island!

Next year, I gave birth to my only son. For delivery, reluctantly I had to come down to Kolkata fearing about any complication.The nearest secondary care was in Dhubri, which was 6-7 hours drive from the garden. 

I returned to my job when my son was 40 days old.Soon we realized that for his immunization we should take him to Coochbehar, a 4-5 hours drive on an undulated village road.Moreover, the scorching heat in the month of June was unbearable.

I and Shantanu discussed an alternative, whether we could get the immunization done in the garden.Till then, there was no facility for immunization, as the tea garden workers were against any kind of injection to their children. 

How much we tried, we failed to convince them. We started our correspondence with the local health bodies and government officials.Also,initiated some dialogues with the union leaders.The solution was to get our son immunized first and show the local workers that “doctor Sahab’s son” had received the immunization.

Finally, the day came.My son got immunized. He was the first to receive the shot in the immunization camp. 

After that, there was a procession.The union leader led the procession,carrying “the example” on his back,showcasing him to the local workers.The message was conveyed that if the doctor was ready to give the injection to his son,it was important for the others to do the same.Then there was a big queue in the camp and that was the beginning of the immunization in that garden.

The roller coaster of my life took me from one extreme to the other. After practising evidence-based, guideline-driven medicine in one of the poshest practice in the UK, it was hard to swallow the harsh reality of a remote tea garden.

But at this juncture of my life, I can still visualize two young doctors putting their heart and soul to improve the life of a few backward poor tea-garden workers.

Rural agony to smile

 

 Dr. Pawan KB Agrawal

       

We all are bound to experience pain at least once in our lifetime in one form or the other. The severity of pain is subjected to individual experience and determination to tolerate. At times the pain bound us to kneel in front of someone whom we expect to be powerful enough in a hope that we will be relieved. 

Being a doctor, determined to face the rural challenges to bloom a light of happiness in those desperate faces with excruciating pain coming across such helpless yet hopeful patients is a routine.We do grade pain but often we are not able to address the individual experiences adequately.Nevertheless we always thrive amidst our limited resources and destitution of our fellow patients to help them sustain through their difficult times and at times these turmoil carve a beautiful story to inspire courage and hope in a doctor patient relationship. 

A week back I had this patient 32 years in one of the emergency beds during morning rounds.Two hours earlier I was informed by my colleague medical officer about receiving him in agonising pain in his abdomen which started from his scrotum the previous day.The pain had started the earlier morning.Since there were no vehicles to carry him and he could not walk for three hours with the pain, helpless he prevailed throughout the afternoon alongside his ignorant wife and three small children not knowing what was awaiting him. 

Rather than taking him to a religious healer, they preferred him receiving care in a hospital. A wise and often rare scenario in most of our deprived areas where these religious healers are the only prospects.

With the dusk, some of his relatives finally fetched a jeep and a ride of two hours along the bumpy gravelled roads and finally landed him in our emergency ward. Whatever be the reason pain must not happen. This is what we often emphasize to our fellow medical service providers. 

He received some pain killers while he was being examined and investigated. We established the diagnosis of right obstructed inguinal hernia and explained the patient & his relatives that he needs to be operated as soon as possible in order to save the part of his intestine that had come out as hernia and had been stubborn not to go back.

We could not be sure though if the part of his intestine needed to be cut and repaired. As a general practitioner, a generalist, we are regularly operating hernia that goes in spontaneously but a situation like this where a part of the intestine might need to be cut put us in dilemma given limited instruments, anaesthetic expertise and post operative care. 

Another challenge poking us was his referral, a journey of 10 hours by jeep depending on a driver to the nearest higher hospital in Dhangadi,far western Nepal in case the patient party agreed. 

We explained and discussed the scenario with the patient party, scrutinised every option in details. It would have been best if we could refer him in an ambulance with a paramedic to Dhangadi. But it was yet far from happening. 

The turmoil of helplessness,poverty and health care resources in each of us endured the entire night and settled in the afternoon as we, doctors and patient party eventually concluded to put the situation on faith and proceed with surgery in our hospital. 

The patient party agreed that if surgery goes wrong or he dies,they would not raise any claim.A life was on our hands then.How could we not do our best and help him survive was a challenge. 

He was rushed into the operation room almost forty hours later.Together with another generalist Dr. Bikash who is also my mentor since I started working with Possible in Accham two months back.

We put him under spinal anaesthesia and took every precaution available at our disposal. As we explored, the faith or whatever we name it served us with a hope that the part of intestine might survive.It was almost on the verge to die, had we opened him few hours later or had referred him.The anxiety diminished with a sigh of relief. 

After he was shifted to the ward, we prohibited him to eat and had him keep on intravenous fluids.After two days we started with liquids and had him have usual diet on fourth day. He was then walking happily without pain and discharged on seventh day after we are pretty sure that the complication would not happen. 

Sometimes we do end up with a climax where a family turns upside down with an unexpected helpless death of the beloved on a hospital bed.But to our faith & the conviction of his fellow relatives,this time a life in despair was restored with balance and smile for his new journey back home with his small family.

Fresia - Story of a Mapuche Women

   

Imagene: La ruca (Vivienda Mapuche)

Dr.Rossana Betancur Escobar 

         (Original Story in Spanish. Translated into English by Mayara Floss) 

         My name is Fresia. I am a woman, Mapuche, 68 years old.I belong to a rural community towards the coast of Chile. My ancestors are of origin is Lafquenche*. I live with my daughter Rosa.She is the youngest of my children.I had 4 children. The others men went out to try their luck to Santiago ...There they formed a family. A year ago they returned with their wives and grandchildren to a house next to mine.

      A year and a half ago my health declined.I did not feel very well.I was without courage, nor the strength to go and sell my vegetables to the people or feed my animals.

                                     ... Same time my partner left ... 

      Rosa started to worry. She took me to the Machi** and said it would be good if we go go to the doctor but before we did a ceremony to heal my spirit she wanted to go elsewhere.

       We went to Carahue***. How strange was everything ... I do not remember much that they told to me.I only had many examinations.One of them was very unpleasant - a tube by the mouth.Before the examination I did not want to eat.After the examination I was worse and vomited.

        We went back to the house but my daughter was quiet.Next time we stayed an hour in Temuco with other doctors.They examined me & told that I have a cancer in the esophagus ...The only thing I noticed was the young lady in front of me put her hand near my heart ... that place was hurting me for so long.

        My daughter left me in a chair. Waited to be comfortable and said  "Mommy, I have to talk to the doctor" ...
   
         After a while she came back by my side ... I do not know why, but I felt that she had cried. But I did not want to ask her. “They  can not operate because you are very thin ...”. “Well, dear, I told you ... it will be a long wait”.

       We were in the micro bus to return to our house with my eyes fixed at the window ...
 I remembered how my children were born,I attended my sick mother,left her house to follow my partner,told my children that they will study because I was not going to stay for sowing... and now I realise that they are my seed.

      That night  was the most beautiful one.My partner came in my dream.He said: "Fresia do not follow me,you have to go back to the doctors,take good medicine and get fat.Children still need you .. Every time you need me, I'll be by your side ...". This gave me strength to fight back.

      Here we went again ... to Temuco. I'm going to take chemotherapy.They say it's for the tumour to shrink. But before they have to put a hose outside of my throat  so I can feed.

     The return to home was different today... I feel happy ... I look in to mirror and found that I have recovered.Who I am ... I AM FRESIA ... AND I AM HERE.

* The Lafquenches or Lafkenches is the name given to those Mapuches who inhabit coastal areas of the region of La Araucanía at the province of Valdivia in the Southern Zone of Chile.

**Machi: Local folk healer

*** Carahue: A city and commune in southern Chile. It is located 56 km west of Temuco on the northern bank of the Imperial River. 

Author:

Rossana Betancur Escobar is a resident doctor in Family Medicine at U de la Frontera in Chile.She started to write this material as a compilation of life histories of her patients throughout her 9 years of work. This is mainly based on rural health and cultural relevance as Mapuche population predominates in the area which she respect and greatly admire. In 2009, she started working in a Health Unit as a family doctor, at Hernan Henriquez Hospital in Temuco, Chile. The unit was responsible for caring the the patients in their homes whether due to acute pathology or terminal cancer. People come from all over the region and from the city.She continue to attend a large percentage of rural population.She is trying to get the attention of her colleagues in other specialities in a hospital of high complexity to raise awareness about patients being cared at home and with the support of their families. So was born this idea to tell patients life stories and how they have experienced the sick. Today she is  working in a rural health centre inserted in the interior of Mapuche communities and she hope to write more stories.



Spanish version
Fresia

Imagene: La ruca (Vivienda Mapuche)

                   Mi nombre es Fresia. Soy mujer,mapuche,tengo 68 años. Pertenezco a  una comunidad rural, hacia la costa. Mis ancestros son  de origen es lafquenche.Vivo junto a mi hija Rosa.Ella es la menor de de mis hijos.Tuve  4…los demás ,varones,salieron a probar suerte a Santiago…por allá formaron familia.Hace un año volvieron,con sus esposas y  mis nietos,construyeron sus casa junto a la mia.

              Un año y medio atrás,mi salud decayó.No me sentía muy bien, estaba sin valor, ni fuerzas para ir a vender mis verduras al pueblo, o alimentar mis animales.

                                   

                               …Mismo tiempo que mi compañero partió…

                  Rosa se empezó a preocupar.Me llevó donde la machi y ella dijo que sería bueno que fuera al médico ,pero que antes hiciéramos una ceremonia para sanar mi espíritu , que quería irse a otro ladoFuimos a Carahue.Que raro se veía todo…No recuerdo mucho que me dijeron, solo que tenia que hacerme muchos exámenes. Uno de ellos muy desagradable, un tubo por  laboca.De antes ya no quería comer,después del examen hasta vomité.Volvimos a la casa, con mi hija…calladitas.

                 Al tiempo ,le entregaron una hora para Temuco,donde otros doctores.Meexaminaron.Me  dijeron que era un cáncer, en esófago …yo lo único que me fijé era en la señorita al frente mio que se ponía la mano cerca del corazón…ese que me dolia tanto, hace tanto tiempo.

                 Mi hija me dejó en una silla..”espérememamita,tengo que hablar  con el doctor”…Al rato estaba de nuevo  a mi lado…no sé porque sentí que había llorado,pero no le quisé preguntar.”Mamita el doctor dice que no se puede operar, porque está muy flaquita…Bueno hija, le dije…tocará esperar”.

                   Ibamos en la micro de vuelta a nuestra casa, con la mirada pegada a la ventana….recordé cuando nacieron mis hijos…cuando atendí a mi mamita enferma…cuando dejé su casa para seguir a mi compañero….cuando le pedí a mis hijos que estudiaran porque yo no me iba a quedar para semilla…y ahora me doy cuenta que ellos son mi semilla.

                   Noches atrás, fue la mashermosa.Mi hombre, en sueños me vino a visitar…”Fresia no me sigas, tienes que volver a los doctores, tomar buen remedio y engordar.Aun haces mucha falta a los nuestros…Cada vez que tu me necesites, a tu lado estaré”….

                  Aquí vamos de nuevo…a Temuco.Me van a hacer quimioterapia, dicen que es para que el tumor achique.Pero antes tienen que poner una manguera, esta vez por fuera de mi guata, para que pueda alimentarme.

                  El regreso a casa hoy es diferente…me siento contenta..miro y me encuentro…he recuperado quien soy…SOY FRESIA…Y AQUÍ ESTOY.

Author:

Rossana Betancur Escobar es  residente segundo año Medicina familiar en la U de la Frontera. "Este material inedito, es el que he empezado a preparar  y que es la recopilacion de las historia de vida de mis pacientes a lo largo de mis 9 años de trabajo. Este se ha dado principalmente en salud rural y con pertinencia cultural,donde predomina en mi zona la poblacion Mapuche,la cual respeto y admiro mucho.A partir del año 2009 comencé a trabajar  en una unidad a cargo de un medico familiar en Hospital Hernan Henriquez de Temuco,Chile, una unidad que atiende pacientes en sus domicilios, ya sea por patologias agudas o cancer terminal.Llegan personas de toda la region y de la ciudad y sigo atendiendo un gran porcentaje de poblacion rural. Buscando una forma de encantar a mis colegas de otras especialidades, en un hospital de alta complejidad,para que deriven pacientes para ser atendidos en su casas y con apoyo de sus familias, es que nace esta forma de contar sus historias de vida y como han vivenciado el enfermar.Hoy me encuentro trabajando en un centro de salud rural, inserto al interior de comunidades mapuches….ahí se comenzará a escribir nuevas historias…."

Skardu

Dr. Sanam Shah

F lives in a small brickhouse along the river stream. She lives with her husband and an adolescent son. On first instance there is something truly enchanting about her surroundings; im distracted by the sky so blue, tugging at me to get away from my city, 2000 km away near the sea. This is Skardu. It is home to three famous mountain ranges namely Himalayas, Hindu Kush and Karakorum and people reside in the foothills despite the natural upheavels and unrests; enough to lure us there in an instance. Lack of engulfing high rise buildings, the city traffic and general urban craziness would make it an ideal place to retire, I thought to myself. But I am moved by something unsettling about her demeanour. She spoke fluent Balti and conveyed phrases with long pauses. I try to connect with her in Urdu, she nods in reply. However, I wait for her son to return with her bag of medicines that she has been taking for a long time.

I take a breather and admire the lovely backdrop. The clouds hang low and I could almost reach up and try to touch one and the surrounding peaks are draped in the early winter snow, glistening under the rising sun. I almost imagine moving up here in the countryside seeing people like F who have been living in this town since a very long time. A nearby river stream fills the silence.

I learnt that there is a big district hospital some distance from this place serving two districts in this town and a bunch of smaller clinics serving this town of approximately 700000-800000. The number of doctors practicing there remains short. The hardest hit are women as they are compelled to see male doctors due to few female doctors serving the area. The doctors themselves are overworked in these challenging circumstances.

So the son finally arrives with a big white plastic bag that I empty on the table before me. To my astonishment there are numerous strips of Levofloxacin that she has been consuming for the last two years that apparently has not made her any better anyways. I look up at her quizically and reconfirm her history that is clearly pointing towards asthma and allergic rhinitis. I dramaticaly ask the family to discard any remaining strips and to avoid using in the future. I write a prescription of anti asthmatics and hand the son with my number in case of any questions and concerns in the future.

This is just one family I chanced to see during my last travels and I begin to think about the other families that make up approximately 800000 population in this town. Its probably just wishful thinking but I pray about having graduate programs in these locations in context of the needs of the local population and someway of retaining health professionals here who often prefer urban centres due to myriad instances like lack of facilities; public-private partnerships that can address the health care challenges and perhaps someday see the establishment of a medical school here!

Five days later when I moved back to work I still thought about her and the numerous challenges meted out by nature both complex and multifactorial. I felt guilty of the urban comforts and started to look at life from perspective of people residing without them on less than 5 dollars a day income. Even after three months of returning, I think about them and their smiling faces and I twinge to return and serve the people and enrich my life with the real stories of life and living in the real world of rural and remote health care. Thats when I think about the neccesity of primary care in developing countries and the need to mobilise a strong workforce of ancilliary health workers besides doctors and nurses. A part of me is there that will cause to return and I would be happy to succumb as long as I can.

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Sanam Shah - Editor of the Blog Rural Health Success Stories
WONCA South Asia Region